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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202878
Report Date: 01/23/2024
Date Signed: 01/23/2024 02:52:07 PM


Document Has Been Signed on 01/23/2024 02:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:EASTLAKE VILLA HOME CAREFACILITY NUMBER:
445202878
ADMINISTRATOR:RECINTO, RACHELLEFACILITY TYPE:
740
ADDRESS:591 ARLENE DRIVETELEPHONE:
(213) 400-4341
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:10CENSUS: 3DATE:
01/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tyrone VegaTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Tyrone Vega.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the kitchen area and observed there to be a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. LPA observed locked drawers for sharp objects and cleaning supplies.

LPA Marrufo toured 6 out of 6 resident bedrooms and observed each bedroom to have functioning lights, bedding, and furniture. LPA tested the smoke detectors in each room and in the hallways, and the smoke detectors functioned properly when tested. Two out of two carbon monoxide detectors functioned properly when tested. LPA Marrufo observed the alarm system on the exit doors functioned properly when tested.

LPA Marrufo toured two out of two resident bathrooms, and each bathroom had working lights and available soap and paper towels. The showers had non-skid mats and shower chairs. The bathroom water temperature was 114 F. The outside area exits were clear of obstructions.

LPA Marrufo reviewed resident and staff records. The resident records, including the Centrally Stored Medication Logs, were complete. The staff records were missing the LIC503 Health Screening form for staff S1-S3. The facility was also missing an Emergency Disaster Drill Log.

Advisory Notes were Issued. See LIC9102 for more information.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Tyrone Vega and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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